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Abstract

The HIV epidemic coupled with the assumed benefits of infant formula for the children
of all HIV-infected mothers have in complex ways changed public ideas about infant
feeding and represents a threat to well established breastfeeding practices. In the
wake of the confusion that postnatal prevention of mother to child transmission of
HIV (PMTCT) interventions have created among HIV-infected mothers, infant feeding
counsellors and the public at large, it is time to reinstate the principles of the
Innocenti Declaration to protect, promote and support breastfeeding in the context
of HIV. The challenge that lies ahead is a search for ways to restore the trust in
breastfeeding as the normal and safest way to feed an infant. This requires continued
research as well as concerted advocacy and action.

Introduction

As a final note, let us return to breastfeeding for a moment and discuss how to counteract
the pressures that have been exerted against breastfeeding in the context of HIV.
As history shows, the threats to breastfeeding have changed over time. During the
last decade the greatest threat to breastfeeding has been the confusion over infant
feeding in the wake of the HIV pandemic. Through national and local PMTCT programmes
and HIV information campaigns, the global community has learnt that breastfeeding
in HIV-infected mothers may be a risk to child survival and should, if possible, be
avoided. The uncertainty that this has generated is illustrated in this thematic series.
In the early phase of the national and local PMTCT programme implementation, breastfeeding
advocacy groups were accused of having their "heads in the sand" about the transmission
of HIV through breastfeeding. The existing evidence of the superiority of breastfeeding
in terms of infant survival, and the 2010 infant feeding guidelines promoting breastfeeding
as the first choice of infant feeding method, have demonstrated that the advocacy
groups were right in their firm and concerted action to protect breastfeeding. One
lesson is learnt: replacement feeding has substantial negative unintended consequences
for the individual mother, for her infant, for households and for health systems.
In the aftermath of a decade of trial and error in developing guidelines and implementing
postnatal PMTCT programmes, the trust in breastfeeding thus needs to be restored.
The challenge is how to 'turn the tide' or change the mindset of PMTCT counsellors,
mothers and significant others towards breastfeeding as the safest way to feed an
infant. The research studies reported in this thematic series suggest that this may
prove challenging given the legacy of efforts to implement earlier guidelines. In
the first concluding remarks we focused on global policy documents and lessons learnt
[1]. Now in this final paper we consider this challenge in terms of the agreements in
the Innocenti Declaration which was adopted in 1991 and reaffirmed in 2005 [2]. The Declaration considered actions around protecting, promoting and supporting breastfeeding
that are still valid, and that should be reiterated in the context of HIV.

Protecting breastfeeding

Protecting breastfeeding remains the most fundamental activity in this regard. According
to the Innocenti Declaration women who are already breastfeeding should be protected
from influences that might discourage them from continuing to breastfeed such as the
promotion of breast milk substitutes [2]. The HIV epidemic coupled with the promotion of infant formula to HIV-infected mothers
have changed public ideas about infant feeding and together represent a threat to
well established breastfeeding practices. The unethical marketing of infant feeding
formula in low income countries in the 1970s was a purely commercial measure, and
was counteracted as such by the endorsement of the International Code of Marketing
of Breast-Milk Substitutes by the World Health Assembly in WHO in 1981 [3]. In the wake of the HIV pandemic, the promotion of infant formula has been redefined
and to a greater extent been justified as a measure to prevent HIV transmission from
mother to child. Free infant formula to HIV-infected mothers has in fact been raised
as a human rights issue and compared with the fight for free access to antiretroviral
treatments (ARVs) [4]. This highly problematic comparison between infant formula and ARVs in human rights
discourse has met stark opposition from various sources [5], and feeds into the ongoing debate on choice, on the mother's right to breastfeed
and the child's right to be breastfed that the editors of IBJ, among others, have engaged in [6,7]. Central to the ethics surrounding the marketing of infant formula is 'the right
of the infant to be breastfed' in the sense that no-one may interfere with a mother's
right to breastfeed [6,7].

In sub-Saharan Africa however, it is notable that the normative foundation of breastfeeding
and the social sanctions expected and experienced by women who are not breastfeeding
have been important factors counteracting commercial pressures to formula feed [8-10]. Protecting breastfeeding involves protecting local breastfeeding knowledge and practices
from undue interventions. It involves resisting commercial promotion of baby foods
in the market and in the health care system by upholding and promoting the Code on
the Marketing of Breastmilk Substitutes nationally and locally [3]. In many countries the Code is still not enforced, and adherence remains voluntary.
Whenever breastfeeding is threatened new opportunities present themselves for expanding
the market for commercial baby foods. Hence '. . . urgent action is required to ensure
[that] the principles and aims of the International Code and related resolutions of
the World Health Assembly are implemented'[[7] p. 1].

Promoting exclusive breastfeeding

The promotion of breastfeeding aims to persuade women to breastfeed [[2] p. 5]. In sub-Saharan Africa where breastfeeding remains normative, promotion of
breastfeeding is primarily geared towards exclusive breastfeeding, because here as
in most parts of the world, exclusive breastfeeding is not customary. Deep-seated
cultural factors such as particular traditions attached to the introduction of other
fluids and feeds can strongly influence infant feeding practices. But poverty may
be an even more important barrier in the promotion of exclusive breastfeeding [7]. It is very difficult for women to succeed in exclusive breastfeeding for six months
when they depend on generating an income from work which is added to their domestic
chores. They may need to leave the baby with other care-givers from just a few weeks
postpartum [11]. Poverty creates situations where there is in fact no choice - one eats what is available,
and feeds children what is available, with the support of the partner that is available.
Many women also fear or, through bio-behavioural feedback, actually experience breastmilk
insufficiency [10-12]. Furthermore, since the implementation of postnatal PMTCT began, exclusive breastfeeding
has in many places become associated with HIV-infected mothers. This further complicates
its promotion among both HIV-infected and non-infected women [12].

Therefore, a challenge is to promote exclusive breastfeeding as the normal and the
safest feeding option for all, as the recent WHO guidelines on HIV and infant feeding
now do. The principles of the Baby Friendly Hospital Initiative (launched in 1991
and updated and expanded in 2009) [13], building on the Innocenti Declaration [2], are among the interventions that are planned revitalized in health facilities at
all levels in the future.

Supporting breastfeeding

Exclusive breastfeeding for six months is a great challenge even for mothers who enjoy
economic and social security. As Beasley and Amir pointed out in an editorial in this
journal, 'As individuals, women are powerless to counter the complexity of social
forces that interfere with exclusive breastfeeding their infants for six months' [7]. A major threat to sustain exclusive breastfeeding is the lack of social support.
The experiences with postnatal PMTCT programmes so far have clearly demonstrated that
in order to succeed in exclusive breastfeeding for six months, support is critical,
both economic support to strengthen food security and social support from partners
and peers.

Partner involvement in the sense of sharing HIV test results is often seen as a necessary
condition for successful adherence to infant feeding recommendations in a PMTCT context.
However, disclosure to the partner is often perceived as an ordeal and may not have
the intended effect if there is a lack of sensitivity to the women's fear of blame
and rejection [8]. Nevertheless, finding new and more effective ways and means to involve partners
more systematically and safely needs to be more strongly emphasized in the implementation
of the new 2010 guidelines [14].

Programmes for peer support for exclusive breastfeeding critically depend on the establishment
of trust, and thus need to take the social and political context into consideration
in programme design [15]. Locally adapted breastfeeding support groups modelled after the 'La Leche League'
approach could be promoted more widely in sub-Saharan Africa in order to support women's
efforts to fight for social and political conditions that facilitate both exclusive
and extended breastfeeding for all.

In order to support breastfeeding beyond six months and after complementary feeds
are introduced, the concept 'prolonged breastfeeding' emerges as inappropriate since
it seems to indicate that breastfeeding takes place for 'too long'. In the editorial
of this thematic series and in these final remarks we have replaced 'prolonged breastfeeding'
with 'extended breastfeeding' to communicate that this practice is beneficial and
should be encouraged and supported.

Research and advocacy

Protecting, promoting and supporting breastfeeding requires continued research as
well as concerted advocacy and action. However, some key questions arise about how
research results can be brought forward to new policies, and how researchers and activists,
representing different entry points, can join forces and pull together to protect,
promote and support breastfeeding.

Drawing implications from research is a challenging task. In the HIV and infant feeding
field there are many different actors or disciplines working on the basis of their
specific and limited paradigms. While the HIV experts aim to eliminate HIV transmission
from mother to child through the elimination of breastfeeding in HIV-infected women,
the child survival experts focus on HIV-free survival and advocate for breastfeeding
[16]. Miriam Labbok argues for 'transdisciplinarity' in the sense that different disciplines
come together "not only to address a predefined problem from each one's perspective,
but rather to together define the problem to be addressed" [16]. In order to achieve synergies between different disciplines that influence the HIV
and infant feeding policy, she argues that breastfeeding should be seen as a part
of the reproductive continuum together with conception, pregnancy, birth and family
planning [16]. In practical terms this means an integration of breastfeeding programmes with other
reproductive health programmes as exemplified in the revised 'Baby Friendly Hospital
Initiative' which, in addition to the 'Ten steps to successful breastfeeding' also
include standards and goals for birthing and birth spacing [16].

We support this view on the need for transdisciplinarity in the definition of the
problem of HIV and infant feeding. In order to ask the right questions and to reach
policy makers on global and local levels with our results, we need to draw upon evidence
from different disciplines and use different kinds of methodological approaches including
epidemiology, biomedicine and ethnography. We need hard facts and numbers, but we
also need narratives documenting the experiences of particular people including mothers
and fathers, peer counsellors and health workers.

However neither stories nor numbers generate policy change by themselves. In order
to make an impact on infant feeding policy, researchers need allies within breastfeeding
advocacy groups that can effectively utilise research results in their advocacy work.
Actors like WABA (World Alliance for Breastfeeding Action) which takes its mission
from the Innocenti Declaration; IBFAN (the International Baby Food Action Network)
that takes its mandate from the Code on the Marketing of Breastmilk Substitutes; and
La Leche League and other mother support groups that provide practical help and support
for new mothers who want to breastfeed, have long traditions with research-activist
collaboration [17]. There may further be a need for the research community to create allies across social
movements; with the women's health movement, and with sexual and reproductive rights-,
environmental-, and human rights movements [16-18].

But when working across these single issue causes, we need to be aware of potential
conflicts of interests. Advocacy groups can move fast, but because they are ideologically
driven they can make counterfactual errors. Recent examples that involve unanticipated
threats to breastfeeding by advocacy groups include the labelling of breast milk "the
world's most polluted food" by Greenpeace [19], the characterization of breastfeeding as a "cause" of HIV infections by HIV education
campaigns, and the demand for free infant formula as a human right by treatment advocacy
groups. In order to prevent such counterfactual errors, the research community should
to a greater extent take on the responsibility to ensure that advocacy groups are
working on the basis of up-to-date and unbiased knowledge.

A final remark

During the symposium in Rosendal, participants noted that the postnatal PMTCT initiative
has brought western and public health biases to local practices that have been adaptive.
Lactation is an ancient adaptation in mammals that has been shaped by evolution [20]. Indeed, recent analyses of the continued relevance of the evolutionary forces shaping
breastfeeding highlight the fact that it has never been lost to any species and that
the same functional benefits of breastfeeding for infants and mothers persist in humans
as in all other mammals [20]. The scientific evidence base warns against hasty dismissal of the evolved benefits
of breastfeeding. The experiences of postnatal PMTCT interventions add substance to
this stand. In future, the global health professional community should be more sceptical
of claims about the risks of breastfeeding.

The challenge that lies ahead is to search for ways that will protect, promote and
support breastfeeding in ways that will reinstate the trust in breastfeeding as the
normal and safest way to feed all infants. The 2010 WHO HIV and infant feeding guidelines
support this trajectory.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

KMIM and AB wrote the first draft of the paper drawing heavily on PVE's summing-up
paper from the workshop. DWS and MMDP contributed to subsequent drafts. SCL provided
important inputs in the planning phase. All authors approved the final paper.

Acknowledgements

The workshop recruited students from different NUFU (The Norwegian Programme for Development,
Research and Education) projects involving partner institutions in Norway and in sub-Saharan
Africa. We sincerely thank NUFU for providing the Norwegian research milieu with the
opportunity to work with African institutions on research and competence building
in areas of health and health care. NUFU also funded the workshop including the travel
for participants and facilitators from abroad.

We thank all the students who have contributed with their papers on various topics
related to PMTCT. Without their collaboration and patience this thematic issue would
not have materialised. We also thank our home institutions for providing us with the
time and goodwill to plan and organise the workshop. These include the Centre for
International Health and the Department of Public Health and Primary Health Care,
University of Bergen; The Faculty of Health and Social Sciences at Bergen University
College; Fafo Fafo Institute for Applied International Studies; Department of Anthropology,
University of Toronto, Canada; Department of Anthropology, York University, Canada;
Muhimbili University of Health and Allied Sciences (MUHAS), Tanzania.

Finally we thank the editor of International Breastfeeding Journal, Lisa Amir for
accepting to publish this thematic issue on breastfeeding and HIV, for her professional
feedback and for her patience and positive attitude throughout this process.